MSW Electronic Application for Field Education Practicum/Placement
Student Name:
Date completed Form: Click here to enter a date.
Date submitted Form: Click here to enter a date.
FAPE: ☐Yes or ☐No
Directions: Please select your contact person, complete all sections of this form,
and electronically send document to fieldsocialwork@uakron.edu
☐UA Lakewood & Concentration Students, Becky Thomas Bthomas@uakron.edu
330.972.5682
☐ UA Main Campus - Foundation Students, Naomi White
naomi1@uakron.edu
330.972.5978
☐ UA Wayne College – Foundation & Concentration Students, temporary contact person until
June 13, 2016 -Lisa Criteslkc6@uakron.edu 330.684.8707
Please select semester you will begin your field education experience: Choose an item.
Please select program status: Choose an item.
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MSW Electronic Application for Field Education Practicum/Placement
Part I Student Information
Last Name:
First Name:
Date Completed Application:
Expected Date of Graduation:
Student UA ID#:
Date of Birth:
Permanent Address:
Present Address:
Email Address:
Telephone:
Permanent:
Current:
Work:
Cell #:
Part II Student History
Education
High School #1
High School #2
Attended:
Attended:
Graduation Date
Graduation Date
Other/Colleges Attended:
Name:
Dates:
Degree:
Major Subject:
Name:
Dates:
Degree:
Major Subject:
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MSW Electronic Application for Field Education Practicum/Placement
Work (Paid Employment) during past 2 years:
#1
Employer Name:
Position:
Dates of Employment:
#2
Employer Name:
Position:
Dates of Employment:
#3
Employer Name:
Position:
Dates of Employment:
#4
Employer Name:
Position:
Dates of Employment:
Volunteer and/or Community Work during past 2 years:
Organization #1
Description of Activities
Time frame (dates)
Organization #2
Description of Activities
Time frame (dates)
Organization #3
Description of Activities
Time frame (dates)
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MSW Electronic Application for Field Education Practicum/Placement
Part III Student Health
Rate your general health: Choose an item.
Do you have any emotional or physical difficulties which may require special
arrangements in a field practicum placement? ☐Yes (Please Explain) ☐No
if yes, please explain
if yes, please let us know how we may best assist you
Part IV Other Student Information
Will you have the use of a car for field?Choose an item.
Do you have a valid Ohio’s Driver’s License? Choose an item.
Are you presently employed?Choose an item.
If you are employed, place of employment:
Address:
Phone:
Position:
Nature of work performed:
Work Schedule (indicate work hours next to working days)
☐Monday ☐ Tuesday
☐Wednesday ☐ Thursday ☐Friday ☐ Saturday
☐Sunday
Do you plan to work while in field? Choose an item.
At the same job? Choose an item.
Same Schedule? Choose an item.
Field at Placement of Employment (FAPE):
Under certain circumstances, a student may do field at his/her place of employment. The
standards and requirements for this type of field placement are the same as those for all other
placements in the Program.
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MSW Electronic Application for Field Education Practicum/Placement
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The proposed field instructor should be someone other than the student’s
immediate employment supervisor;
Field Instructor should have a MSW/MSSA degree with 2 years post-graduate
employment experience;
Field Instructor should have at least 1 year with the agency; and
Field Instructor should be able to offer the student a minimum of 1-1 ½ hours per
week of individual supervision.
Field assignments should be different from employment activity and educationally
focused.
Students interested in completing their field experience at their place of employment are
required to submit this application, and submit a written Field at Place of Employment Proposal
for approval by the field office. (See form on website: www.uakron.edu/socialwork/ - field
education-MSW Field Information and Forms- FAPE)
If planning to apply for a Field at Place of Employment (FAPE), please provide the following
information:
Agency name:
Agency address:
Contact Person’s Name:
Contact Peron’s Phone # & Extension:
Part V Student Agreement
Important! Signature Box Below
A check in this box, affirms that I hereby attest that all of the information on this
application is true to the best of my knowledge and is the equivalent of my signature. I hereby
authorize it can be shared with the field instructor. I understand that acceptance into the Field
Education Program is determined by the social work faculty and that satisfactory completion of
field is a requirement for completion of the Master of Social Work degree and for graduation. I
understand that if I do not submit all field documents according to scheduled time frame, I may
not receive credit for my field experience during that semester.
Signature Date: Click here to enter a date.
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MSW Electronic Application for Field Education Practicum/Placement
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